What medication helps with anxiety in patients taking vilazodone (Selective Serotonin Reuptake Inhibitor, SSRI)?

Medications for Anxiety While on Vilazodone

Buspirone (BuSpar) is the most appropriate medication to help with anxiety in patients taking vilazodone due to its favorable safety profile and complementary mechanism of action. 1

First-Line Option: Buspirone

Buspirone offers several advantages for patients already taking vilazodone:

• Initial dosing: Start at 5 mg twice daily
• Maximum dosage: Can be titrated up to 20 mg three times daily
• Onset of action: Takes 2-4 weeks to become fully effective
• Mechanism: Non-benzodiazepine anxiolytic that works through 5-HT1A receptor partial agonism (complementary to vilazodone's mechanism) 1
• Safety profile: Does not cause dependence, sedation, or cognitive impairment like benzodiazepines

Buspirone is particularly useful for patients with mild to moderate anxiety symptoms while on vilazodone, and avoids the potential drug interactions or additive side effects that might occur with other anxiolytics.

Alternative Options

For Short-Term/Acute Anxiety Relief:

If more immediate anxiety relief is needed while waiting for buspirone to take effect, consider:

Benzodiazepines (with caution):

• Options: Lorazepam (Ativan), oxazepam (Serax), or temazepam (Restoril)
• Important cautions:
  • Use only for short-term management of acute anxiety
  • Risk of tolerance, addiction, and cognitive impairment
  • Paradoxical agitation occurs in approximately 10% of patients
  • Use lowest effective dose for shortest duration 1

For Patients with Comorbid Depression and Anxiety:

Mirtazapine:

• Initial dose: 7.5 mg at bedtime
• Maximum dose: 30 mg at bedtime
• Benefits: Promotes sleep, appetite, and weight gain; well-tolerated 1
• Considerations: May be particularly helpful if insomnia is a component of anxiety

Important Considerations and Precautions

Avoid These Combinations:

1. Other SSRIs or SNRIs: Adding another serotonergic agent to vilazodone significantly increases the risk of serotonin syndrome 2
2. MAOIs: Absolutely contraindicated with vilazodone due to risk of serotonin syndrome 2
3. Triptans: May increase risk of serotonin syndrome 2

Monitoring Requirements:

• Watch for signs of serotonin syndrome (agitation, hallucinations, confusion, fast heart rate, sweating, tremors, stiff muscles) 2
• Monitor for increased bleeding risk, especially if combined with NSAIDs or anticoagulants 2
• Assess for emergence of suicidal thoughts, especially in the first few weeks of treatment 2

Special Populations

Elderly Patients:

• Start with lower doses of buspirone (2.5 mg twice daily)
• Avoid benzodiazepines if possible due to increased risk of falls, cognitive impairment

Patients with History of Substance Abuse:

• Avoid benzodiazepines
• Buspirone is strongly preferred due to lack of abuse potential

Patients with Comorbid Seizure Disorder:

• Use caution as vilazodone itself has been associated with breakthrough seizures in patients with seizure history 3
• Benzodiazepines may actually be beneficial in this specific subpopulation

Clinical Pearls

• Vilazodone itself has shown efficacy for anxiety symptoms in depression, so dose optimization of vilazodone (up to 40 mg daily) may help before adding another agent 4
• Buspirone's mechanism complements vilazodone's action, potentially enhancing anxiolytic effects without significantly increasing side effect burden
• Patient education about delayed onset of buspirone's effects is crucial to prevent premature discontinuation
• For patients with significant insomnia contributing to anxiety, low-dose mirtazapine may be particularly beneficial

Remember that while vilazodone has shown some efficacy for anxiety symptoms in depression 4, persistent anxiety may require adjunctive treatment with buspirone as the safest first-line option.